Clinical Geriatrics

CASE PRESENTATION
Mr. V is an 83-year-old married man with a history of vascular dementia for the past five years. He is cared for by his 72-year-old wife, with four hours of paid assistance twice per week. Mrs. V attends a caregiver support group at a local senior center and is active in her local Alzheimer’s Association. Mr. V suffered his first stroke five years ago, with right-sided weakness, difficulty with word finding, and cognitive loss. After a period of rehabilitation he was able to return home, using a cane for ambulation. One year later he suffered another stroke, affecting the right parietal lobe. He required more assistance with activities of daily living, and his speech was more rambling and disorganized. His wife feels strongly that he should remain at home, and has become very experienced using behavioral techniques to help provide care. Mr. V has many chronic medical problems, including hypertension, atrial fibrillation, type 2 diabetes mellitus, hypothyroidism, and peripheral vascular disease. He is treated with lisinopril/hydrochlorothiazide 20/25 mg, digoxin 0.125 mg, warfarin 3 mg, and levothyroxine 0.112 mg, all once per day. In addition, he takes rosiglitazone 4 mg and metformin 500 mg twice daily.

Mr. V had become increasingly resistive and aggressive during care over the past several months. He often refused to bathe; his wife offered him cake and cookies as a reward when he cooperated. Mr. V developed suspiciousness with difficulty sleeping. He started screaming at the windows during the night, telling his wife that neighbors were trying to break in. She tried keeping the blinds closed and played soft music, but he continued to yell and bang on the walls. Mrs. V brought him to his neurologist who prescribed olanzapine 10 mg at bedtime. Mr. V started sleeping more at night, but remains aggressive and refuses to change his clothing. He would only take a shower if his wife gave him chocolate cake with ice cream and whipped cream. He gained 15 lbs and became less ambulatory. Mr. V spent a great deal of time sitting on the couch, eating, and talking about how the neighbors were trying to move in and steal their house.

Mr. V missed several appointments with his primary care physician, Dr. B, because he refused to leave the house. Mrs. V arranged an appointment when her daughter could come with them. Mr. V appeared suspicious and told his doctor that he needed to leave because people were trying to break into his house. He had gained more than 20 lbs in the past six months. Mr. V is 5’10” tall and weighs 237 lbs, with a body mass index of 34. He is ambulatory with right-sided weakness. His blood pressure is 148/90 mm Hg. His pulse is 68 bpm and irregular, with an electrocardiogram showing chronic atrial fibrillation. A finger stick glucose done in Dr. B’s office is 210 mg/dL. A blood sample sent to the laboratory reveals an elevated glycosylated hemoglobin level of 10.5%. All other studies, including thyroid-stimulating hormone, digoxin level, prothrombin time, and international normalized ratio (INR), are within a therapeutic range. Mrs. V told the doctor that her husband was constantly talking about “the neighbors” breaking in, referring to a family who lived next door to them more than 20 years ago. She stopped giving him the olanzapine two weeks ago because her daughter told her it was making his diabetes worse. Their daughter is very concerned about the side effects of drugs, and insisted that Dr. B prescribe a medication that would help her father without worsening his diabetes or causing him to have another stroke. She was insistent that Dr. B find “the right medication,” but admitted that she works full time, has her own family, and spends very little time with her parents.

Dr. B wanted to minimize the patient’s risk of having another stroke and adjusted Mr. V’s doses of rosiglitazone and lisinopril to better control his diabetes and hypertension.